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Insurance denials and delayed access to care · Cultural Wars | America Out Loud News

• 0:06
  Welcome to the tow.
• 0:09
  Take a deep breath.
• 0:11
  Take the higher rolls.
• 0:13
  That's what they always say.
• 0:14
  Let's see if they know the way.
• 0:16
  They won't take it from me.
• 0:20
  But don't ever dump yourself with swiping just a dream.
• 0:24
  You made your own so kid can scream.
• 0:27
  Looking overlap with a never ending force.
• 0:31
  You never had the chance.
• 0:33
  So watch it with my friend, because this is what the Nurses Report on America Out Loud.
• 0:58
  I'm your host, Ashley Caputo, registered nurse and functional medicine practitioner.
• 1:03
  Today's episode is one that I've really been wanting to do for a while because it's something I see consistently, not just occasionally, but every single week in some form.
• 1:16
  We're talking about insurance denials, delayed care, and what happens when access to treatment is no longer just a medical decision, but becomes a system decision.
• 1:30
  And before we get into the details of how this works, I want to acknowledge something that shifted the conversation in a big way.
• 1:40
  In late 2024, an insurance CEO, Brian Thompson, was murdered.
• 1:48
  That was shocking.
• 1:50
  It was tragic.
• 1:51
  And I want to be very clear.
• 1:54
  Violence is never the answer.
• 1:57
  But what followed that event revealed something different.
• 2:02
  There was a level of anger, frustration, and pain from people all over the country.
• 2:11
  People sharing their own stories, fighting for care, being denied treatment, waiting while their condition worsened, feeling completely powerless.
• 2:23
  And that kind of reaction doesn't come out of nowhere.
• 2:27
  It comes from lived experience.
• 2:31
  So today I want to break this down in a very real grounded way.
• 2:36
  From what this looks like inside the system to what it feels like for patients and families.
• 2:48
  So I think she's gonna hop on the second half of the show.
• 2:52
  But Amy Whitlock is gonna be joining, and she knows about all of this firsthand because she experiences it with her son on a regular basis.
• 3:01
  The denials, the fight against the insurance company.
• 3:06
  So I think most people assume that if a doctor orders something, then it just happens, right?
• 3:15
  Your doctor thinks you need a treatment, a scan, a medication, you should just be able to get it.
• 3:23
  But that's not how things work.
• 3:25
  That if something is medically necessary, it should be covered, right?
• 3:30
  There's that there's some kind of safety net built into the system to make sure you get the care that you need and you deserve.
• 3:38
  And it's just not how it works.
• 3:42
  What actually happens, it happens in layers.
• 3:46
  There's a prior authorization, step therapy requirements, coverage reviews, pharmacy restrictions, documentation requests.
• 3:59
  And most of this happens behind the scenes, and sometimes you have no idea.
• 4:03
  You know, your doctor orders something, it gets approved, you pick it up at the pharmacy, or you go get your scan, or whatever it is that you need, and you never know about all the things that are happening behind the scenes.
• 4:15
  But then the time comes where something gets denied, and that's when the fight begins.
• 4:22
  So from the patient's perspective, it feels like sometimes maybe it gets approved, but it feels like it takes forever.
• 4:30
  I can't tell you how many people I talk to, and they're like, well, I'm waiting on insurance approval before I can go get this scan.
• 4:38
  I mean, just recently, I had a client that I'm working with, and he was told he has prostate cancer.
• 4:47
  And you know, that's shocking.
• 4:49
  He's young, he's healthy, but told that he has prostate cancer, but they can't tell him anything else until they get a pet scan.
• 4:59
  And two weeks later, he's still waiting on insurance authorization to get this pet scan.
• 5:05
  They won't schedule it until it gets approved.
• 5:08
  So he's just waiting in limbo.
• 5:10
  And you know, that weighs heavy on you when you're just told that you have cancer, but they can't tell you anything more.
• 5:18
  And now you're having to wait on insurance authorization.
• 5:24
  And then sometimes these things get denied, and the patients feel like, why am I not getting what I need?
• 5:32
  Why are they blocking me from getting the care that I need?
• 5:36
  I want to say this clearly.
• 5:38
  Delayed care is not neutral.
• 5:42
  When care is delayed, symptoms continue, conditions progress, and stress builds.
• 5:52
  It's not just an inconvenience.
• 5:54
  And sometimes these things are benign.
• 5:57
  You know, maybe it is just an inconvenience, but a lot of the times someone's health is depending on getting these treatments, these scans, these prescriptions, whatever it might be, and the insurance is holding it up, and it's so frustrating.
• 6:17
  So let's back it up a little bit.
• 6:19
  Let's talk about the anger.
• 6:22
  And that was made so apparent back in 2024.
• 6:25
  This anger is real across the board.
• 6:28
  It doesn't matter which insurance company you have.
• 6:33
  Everybody feels it.
• 6:36
  People are paying monthly premiums, deductibles, co-pays, and then when they need care, that's when the barriers start showing up.
• 6:49
  You know, that's when they hear it's not medically necessary.
• 6:53
  Try something else first.
• 6:55
  You know, that's something called step therapy.
• 6:58
  And that's um, you see that in your pharmacy benefits a lot, because maybe your provider wants to prescribe you a certain medication and it gets denied.
• 7:00
  Pharmacy benefits a lot because maybe your provider wants to prescribe you a certain medication and it gets denied.
• 7:08
  And it's not that it's not covered by insurance, but you haven't gone through the proper steps to get it covered.
• 7:08
  And it's not that it's not covered by insurance, but you haven't gone through the proper steps to get it covered.
• 7:16
  So you might have to try X, Y, and Z before you can move on to that medication that your doctor wants you on.
• 7:16
  So you might have to try X, Y, and Z before you can move on to that medication that your doctor wants you on.
• 7:25
  So those other meds that you have to try, you have to fail at.
• 7:25
  So those other meds that you have to try, you have to fail at.
• 7:29
  Meaning you you get prescribed this medication, you take it, and it doesn't work for you.
• 7:35
  So you move on to the next step.
• 7:38
  And maybe you try that and it doesn't work for you.
• 7:41
  So it fails.
• 7:43
  And then eventually you get to the medication that your doctor wanted you to have in the first place.
• 7:49
  Step therapy.
• 7:50
  And a lot of the times those steps are because the medication is more expensive, and they want you to try alternatives first.
• 8:00
  Sometimes it works out.
• 8:02
  Sometimes the medication's fine.
• 8:04
  But a lot of the times people end up continuing to suffer because they're taking medications that their doctor doesn't feel is going to be beneficial to them to begin with, which is why they wanted the other medication.
• 8:17
  But to get to that other medication, you have to follow these steps.
• 8:21
  It's all very frustrating.
• 8:23
  Sometimes the insurance company will say, we need more information.
• 8:28
  The clinical documents do not support the need for whatever it is that your doctor's ordering.
• 8:36
  And it feels like, you know, to the patients, to the members, to the clients, it feels like I've done everything right.
• 8:45
  And now I have to fight for care.
• 8:48
  I pay all of this money every single month.
• 8:51
  I'm doing the right thing by having insurance.
• 8:54
  I pay my premiums.
• 8:56
  I still have to pay out of pocket.
• 8:58
  And I still have to fight to get the care that I deserve.
• 9:03
  And that fight is exhausting.
• 9:07
  Because it's it's not one phone call.
• 9:10
  A lot of the times it can't even be a phone call.
• 9:14
  You know, you can call your insurance company and maybe maybe you talk to somebody, customer service, and they'll look into it and they will say, Well, you have the right to appeal.
• 9:23
  You know, a lot of it's put back on you to take the steps to appeal the insurance company's decision.
• 9:34
  So they are banking on people not wanting to do that.
• 9:39
  Because who wants to do that?
• 9:41
  Nobody wants to go through all that paperwork, all that frustration.
• 9:45
  It's hard to navigate, it's hard to understand.
• 9:49
  And don't get me wrong, not everybody in the insurance company is horrible, right?
• 9:54
  Like I've worked for insurance companies as a case manager.
• 9:59
  I help people get the care that they need.
• 10:05
  But if you don't know how to navigate the system and find the people within the system to really help and support you, you you feel completely alone and you feel lost.
• 10:17
  You know, not everybody knows that they can call and ask to speak with a nurse with their insurance company or ask to speak with someone who can help them step by step, you know, file an appeal.
• 10:29
  A lot of people don't even know that you can appeal the decision.
• 10:33
  They just go back to their doctor and say, hey, this isn't covered.
• 10:36
  And maybe their doctor gets them a different prescription or just bypass, you know, doesn't do whatever testing it was.
• 10:44
  Um, you know, so it's a hard system to navigate and it's exhausting, it's overwhelming.
• 10:51
  And so a lot of people just don't do it, right?
• 10:55
  Um, and it could be hours on hold.
• 10:57
  You know, you could get transferred to different departments.
• 11:01
  Here's one really frustrating thing is that you call your insurance company, you think, well, I have this company as my insurance, whatever it might be.
• 11:11
  And then you call them about a medication that gets denied, and they say, Well, we're not your pharmacy benefit manager.
• 11:20
  We don't cover, we don't take care of your prescriptions.
• 11:25
  So then you're sent somewhere else, and you had no idea that it wasn't your health insurance company that you thought it was that's now covering your um your pharmacy, you know, all your medications.
• 11:39
  So now you're having to call somebody else.
• 11:41
  And do you have that number?
• 11:43
  Can they transfer you over?
• 11:44
  Can they at least provide the number?
• 11:46
  Now you're having to call someone.
• 11:48
  Um so again, you're having to tell the people the same thing over and over again.
• 11:54
  So that's really frustrating, you know, and you might get transferred to multiple people and you're having to just continue to tell your story while you're calling, and it gets really frustrating.
• 12:05
  Um, and then you have to wait.
• 12:07
  You know, um, Amy, who we're gonna bring on a little bit, she um was told the other day after her child was denied a life-altering medication, to be honest.
• 12:20
  It's IVIG, and without this medication, he declines neurologically pretty quickly.
• 12:28
  He needs this medication in order to function.
• 12:32
  And they received a denial letter, you know, stating that this medication is experimental and it's no longer gonna be covered.
• 12:42
  Although he's been getting this medication for two plus years, he's shown improvement.
• 12:49
  So the therapy has proven itself to work, and now all of a sudden they're gonna take it away from him.
• 12:57
  Well, it's not the medical insurance that's denying it, and it's not technically the pharmacy benefits, it's the specialty pharmacy.
• 13:06
  So there's three companies involved in all of this.
• 13:10
  And if you don't know how to navigate it, you don't know who to call.
• 13:15
  So it gets overwhelming and you feel like you can't fight the system.
• 13:23
  And I've seen, I've seen patients, you know, finally get the treatment they need and finally get the meds that they need.
• 13:33
  And it can be life altering.
• 13:35
  It changes the trajectory of your life.
• 13:37
  You know, I have I've seen patients that need back surgery that continue to get denied and eventually get the back surgery, and they're so grateful that they finally got it.
• 13:47
  But why do they have to wait and suffer for so long?
• 13:53
  Because the insurance company disagrees with your doctor.
• 13:58
  Your doctor who's sitting right there next to you doing an assessment, making recommendations, went to medical school and specializes in whatever they're doing, and they are advising you to have this treatment, this scan, this medication, and the insurance company swoops in and says, No, we don't agree with this.
• 14:00
  Sitting right there next to you doing an assessment, making recommendations, went to medical school and specializes in whatever they're doing, and they are advising you to have this treatment, this scan, this medication, and the insurance company swoops in and says, No, we don't agree with this.
• 14:22
  We don't think this is medically necessary.
• 14:22
  We don't think this is medically necessary.
• 14:25
  This is excluded from your plan, you know.
• 14:25
  This is excluded from your plan.
• 14:28
  You know, step therapy, you can't take this medication yet.
• 14:34
  People get discouraged.
• 14:37
  They want to give up.
• 14:40
  They become depressed.
• 14:41
  Their symptoms are exacerbated.
• 14:43
  They're having this delay in care that is worsening their condition.
• 14:48
  And it's because of the insurance company.
• 14:52
  And it is infuriating.
• 14:56
  You know, I don't know if everybody understands the impact that this can have on somebody's life.
• 15:07
  You know, um, sometimes it's it's silly things like your hospital stay gets denied.
• 15:16
  And it's because the hospital didn't send over clinicals to the insurance company.
• 15:23
  So they have no idea why you're at the hospital, why you need to be there.
• 15:27
  So they deny it.
• 15:28
  So then the hospital says, oops, and they send over more clinicals, the insurance company reviews it and approves it, and you never even know that it happened.
• 15:41
  Other times it's completely life altering.
• 15:46
  Maybe a hospital stay is denied.
• 15:48
  And I've seen this firsthand, where the insurance company doesn't think that it was medically necessary for you to be at the hospital.
• 15:57
  Well, here you are, the patient at the hospital, admitted, getting care, getting treatment, trying to focus on your own recovery.
• 16:06
  You have no idea that the insurance company is denying your stay.
• 16:11
  Maybe you get rushed into discharge and you feel like you're being sent home, you know, too soon or without everything that you need.
• 16:20
  And then you get home and you start getting bills in the mail saying the insurance company denied your stay, and now you're going to be responsible for payment.
• 16:31
  We're not talking about a couple hundred dollars, right?
• 16:34
  When somebody's admitted in the hospital, we're talking thousands and thousands of dollars.
• 16:42
  And now these people that have been out of work, that have been sick, that have been struggling, are now faced with having to pay this bill, and they've been out of work.
• 16:55
  So their bills are already behind.
• 16:58
  Maybe they don't have a lot of money saved up, and now you've just put this financial burden on them because an insurance company disagrees with doctor's recommendations.
• 17:10
  And who suffers?
• 17:13
  The patient.
• 17:16
  Because the hospital's not going to keep you if they know the insurance company is not going to pay.
• 17:21
  So they're going to push your discharge and try to get you out.
• 17:26
  Because now they know that they're not going to be getting payment.
• 17:29
  The insurance company runs the healthcare system.
• 17:34
  And it's disgusting.
• 17:36
  You know, this it doesn't just affect the patient either.
• 17:40
  It affects the family.
• 17:42
  It affects their job.
• 17:44
  It affects their mental health.
• 17:47
  This is, I mean, this is where the system gets really real.
• 17:51
  This changes people's lives.
• 17:54
  Decisions by an insurance company change people's lives and not always for the good.
• 18:03
  You know, let's let's talk about the business side a little bit because I get it.
• 18:08
  The insurance company is a business, right?
• 18:12
  Insurance companies make money when they bring in more than they pay out.
• 18:21
  Let me say that again.
• 18:31
  I mean, it makes sense, right?
• 18:33
  You're making a profit.
• 18:35
  They bring in money through premiums, employer plans, government programs, and they control spending through approvals, denials, and restrictions.
• 18:52
  So when people say they make money by not paying, it's simplified, but it points to something very real.
• 19:01
  The system is built to control medical costs.
• 19:06
  Now, to be fair, it's a complex system, and not every denial is malicious.
• 19:15
  But what is true is that the system is not designed around the patient experience, right?
• 19:22
  And the patient definitely feels that.
• 19:25
  People feel that.
• 19:29
  So one thing that I think is really overlooked.
• 19:38
  And I I don't know if everybody's aware because I really didn't have any idea.
• 19:45
  But we we constantly blame the insurance company, and they play a big role in in a lot of this.
• 19:51
  But the the person that gets skipped that kind of gets overlooked, but is very much responsible for a lot of what happens is the employer.
• 20:08
  Nobody says anything about the employer, especially these huge, like large corporations that employ thousands of employees, right?
• 20:18
  Like you have uh a company that is everywhere across the United States, they all have the same insurance.
• 20:28
  And maybe they give you the option of picking different plans, or maybe it's whatever, you know, they have one or two plans you choose from.
• 20:35
  A lot of the times the smaller companies, they you don't have as many options, right?
• 20:41
  Maybe your deductibles higher, that kind of thing.
• 20:45
  But I remember being, you know, an employee.
• 20:50
  And when you're looking at your insurance, you're thinking, oh my gosh, I can't believe I can't remember who it was.
• 20:56
  I think I had, it was at Aetna, I don't know.
• 21:00
  uh I don't know.
• 21:01
  I had some insurance when I when I worked at a hospital.
• 21:01
  I had some insurance when I when I worked at a hospital.
• 21:04
  And I remember looking at the plans and I'm like, this is crazy expensive.
• 21:04
  And I remember looking at the plans, and I'm like, this is crazy expensive, you know, every month to have to pay this much money.
• 21:10
  You know, every month to have to pay this much money.
• 21:13
  And I don't even I like I never use it, right?
• 21:13
  And I don't even I like I I never use it, right?
• 21:17
  Like I I was young and healthy and but then I thought to myself, well, you know, what do I what do I do if something happens and I don't have insurance.
• 21:17
  Like I was young and healthy, and but then I thought to myself, well, you know, what do I what do I do if something happens and I don't have insurance?
• 21:26
  But also you're required to have insurance.
• 21:26
  But also you're required to have insurance with a lot of companies.
• 21:31
  Um so you know you kind of have to pick something right and for a while um it was mandated that you had to have insurance and if you didn't I think you paid a penalty um thanks to Obamacare, which I believe they've they've retracted that they no longer charge that penalty to people.
• 21:52
  But you know you're looking at these plans and you're like man I have to pay this much money you know this much money a month if I choose a cheaper plan my deductibles are higher.
• 22:02
  So if I do need to use it I'm paying out more money.
• 22:07
  And it's really hard to find a balance of you know you don't feel like you're paying an arm and a leg every month but if you did need to use your insurance you're also not paying an arm and a leg, right?
• 22:19
  So you have your deductible and you have your maximum out of pocket.
• 22:23
  And that's where it gets a little confusing because people will be like oh I met my deductible but now you still have $5,000 and you're at a maximum out of pocket.
• 22:33
  So you continue to have to spend money and pay into the the insurance who decides that is it the insurance company is like oh we're gonna make these plans not necessarily what I didn't realize is that the employer plays a much bigger role in deciding your health insurance and your plan than you really think.
• 23:00
  Some employers even create the insurance it is their plan.
• 23:06
  It is not the insurance company's plan.
• 23:10
  It's the employer's plan and then they kind of hire an insurance company to carry it out.
• 23:17
  So while you're getting mad at the insurance company you might need to look deeper and look at your employer what is your employer's number one goal to make money to save money.
• 23:34
  So some of the things that they choose and they decide are not for the health and wellbeing of their employees but it's how can we save money and you see this because you know maybe you have insurance for the year and then when that insurance renews maybe there's some changes that were made on the plan.
• 23:56
  Why were there changes made?
• 23:59
  It's not necessarily the insurance company making changes to their plan but it's your employer saying what else can we do to save money so for instance when we bring Amy on we'll talk a little bit more about this her company that her husband works for made some changes this past year that the pharmacy uh specialty pharmacy changed to some company that I honestly had never heard of but when you go digging into this company they are known for cost savings they have no doctors on board you're not allowed to appeal decisions um and decisions are made based on if a medication is listed in the formulary not based on patient need or medical necessity they take medical necessity out of it and they're only approving medications that the employer has agreed to now do you think the employer is going to agree to a medication that cost 38,000 dollars every time it's administered probably not and that's how we get to the IBIG being taken off of the formulary and being denied.
• 25:21
  So when we come back from break we're gonna bring Amy on and we're gonna talk about this denial and how it's affecting her and her family and kind of dig a little bit more into the insurance company and how all of this works.
• 25:35
  So hang in there hang with us and we'll be right back after this break let's get real let's get loud on America loud talk news yes this is Dr.
• 25:45
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• 28:00
  I was filling her in kind of what we talked about um before the break, we were just breaking down the insurance company, denials, the delay of care and the impact that has on families.
• 28:12
  So I want to jump right back into it, but kind of get a personal perspective because you've dealt with denials.
• 28:20
  So just talk a little bit about um, you know, how these denials affect your son and affect you and your family and um, you know, how frustrating it can be.
• 28:32
  Yeah.
• 28:32
  I mean, it affects affects every area of our life as a family because without the um he's on IVIG, our son's on IVIG, and without that medication, I mean, we have a lot of neurological deficit that sets back in.
• 28:48
  And you can't, you can't live that way.
• 28:50
  It's it's not fair to him, but it's, you know, as a whole, they're not just making judgment on the patient, they're making judgment on the whole family.
• 28:59
  And um, I know our recent denial, the the letter, the legal jargon, the medical jargon.
• 29:06
  Like I had to read it three times.
• 29:09
  Three times to be like, why are we denied?
• 29:12
  And basically the formulary, it was a formulary thing.
• 29:16
  And so what infuriated me the most is the specialty pharmacy won't let us appeal this.
• 29:24
  So what do you do then?
• 29:26
  You know, that's that's new.
• 29:27
  Appeals have always been an option.
• 29:30
  So um, if this had been say, I would have been in full blown panic mode, but thankfully I've got a good advocate.
• 29:37
  And um we tag team this together.
• 29:41
  But for families that don't know how to read these letters, this is their first time opening the mail and they're seeing the the red ink, the the the denial.
• 29:52
  I mean, there's ways to get help.
• 29:56
  I I would recommend an outside advocate.
• 29:59
  Um they work better.
• 30:01
  Um, but yeah, the impact is it's broad.
• 30:06
  Yeah.
• 30:07
  Yeah.
• 30:07
  And I think um, you know, what you said about the way the letters written, you know, I I feel like they bank on that.
• 30:15
  They um I I really do feel like the intention is to intimidate someone and hope that you're not gonna try to fight it and just say, well, I guess, you know, I guess I can't get this.
• 30:30
  And I see that happen a lot.
• 30:32
  Um, you know, I'll talk to somebody and they'll say, well, the insurance company just denied my back surgery.
• 30:37
  And so then they just think there's no hope and there's no other options.
• 30:42
  But um, but then you get people that do fight back, and that's not what the insurance companies want.
• 30:48
  That's not what those, you know, specialty pharmacies want you doing.
• 30:53
  Um, so I I I think there's something to say about that is they they do use that medical jargon um to intimidate and and to keep you.
• 31:04
  Yeah, they make it sound impossible because you know we're we're trained to read these things, we're trained to know these things, but just your average person facing their first denial.
• 31:16
  All I know to do is put the letter back in the envelope and say, well, that's it.
• 31:21
  Yeah.
• 31:21
  And what if what if it's not it?
• 31:23
  Um, what if you can get an advocate?
• 31:25
  What if you can, you know, fight back?
• 31:28
  And you can, you absolutely can.
• 31:30
  There's just steps, you know, there's a process, and um, it's not gonna happen overnight, but it's worth it.
• 31:38
  It's very, very worth it.
• 31:40
  Yeah.
• 31:41
  And I think um, you know, having an outside advocate for situations like this is which, you know, we do through remnant health care.
• 31:50
  We offer advocacy services, and it's such a wide range.
• 31:55
  Um, you know, whether you're in the hospital, family members in the hospital, or it's a situation like this.
• 32:01
  You know, you need somebody that can help you navigate because your first response is you're upset, right?
• 32:08
  You're scared, you're worried, you're upset.
• 32:11
  And it's really hard to think clear and get a a good plan in place.
• 32:15
  Um, and then also finding an advocate on the inside too.
• 32:20
  You know, someone that can help fight from the inside as well.
• 32:24
  Um because it's a hard system to navigate.
• 32:28
  They do not make it easy.
• 32:30
  Before before the break, then the first segment, I was talking about how, you know, you might get um transferred to all these different people.
• 32:39
  You're on hold a long time, you get transferred to five different people, and then they tell you you're just calling the wrong place to begin with, you know, and then you have to call somebody else.
• 32:50
  Um, and then they tell you to wait.
• 32:52
  And that's what happened to you recently.
• 32:55
  They were like, well, we'll have a decision in in three to five days.
• 32:59
  Well, what do you mean?
• 33:00
  You know, like it and it's just it's insane.
• 33:04
  So the it gets um, I've actually talked to people that lose all hope and don't think that they're gonna be able to go on all because of a decision from an insurance company.
• 33:18
  I just I get so aggravated with it because where did we shift where your doctors and their recommendations aren't first line?
• 33:31
  Right.
• 33:31
  Like Yeah, yeah, the insurances in the special department sees they they truly dictate what the doctors can do.
• 33:39
  Um I think there's still a lot of good doctors in the system, but they're in the system.
• 33:45
  Yeah.
• 33:46
  And they can only so much.
• 33:48
  They've kind of been trained like over the years.
• 33:50
  Um, I had somebody recently, I can't remember exactly what it is we were we were trying to do, but um, I said, have you ever thought about this?
• 33:59
  And I I mentioned a medication, and she was like, Oh, yeah, my doctor said insurance won't cover that.
• 34:05
  And I said, Well, no, I sh insurance will cover it.
• 34:08
  Like I I've seen it covered.
• 34:10
  And so the the doctors are conditioned to not pursue different lines of treatment or medications, um, because they're assuming that insurance isn't gonna cover it without even trying.
• 34:24
  I think probably because they've just been beat up by the system.
• 34:28
  Right.
• 34:29
  You know, and we um, you know, because you and I are in Georgia, we um have seen what's going on with Dr.
• 34:37
  Potter.
• 34:38
  Um, if if anybody follows her on social media, but she's kind of calling out the insurance companies because it's so frustrating.
• 34:47
  She'll be going into surgery and she's having to do a peer-to-peer and like plead with the insurance company to allow her to do her job.
• 34:57
  Right.
• 34:58
  And she's got a private practice, and that says a lot about her because to have a private practice, it's a lot of work.
• 35:00
  And that says a lot about her because to have a private practice, it's a lot of work.
• 35:05
  Yeah.
• 35:05
  Yeah.
• 35:05
  You know, and she could just be like, okay, we're private, we're not taking insurance, but she's trying to help everyone on on every, you know, this broad spectrum that we've got with this healthcare system.
• 35:05
  You know, and she could just be like, okay, we're private, we're not taking insurance, but she's trying to help everyone on on every, you know, this broad spectrum that we've got with this healthcare system.
• 35:17
  And so I appreciate the fact that she's still willing to fight for people.
• 35:17
  And so I appreciate the fact that she's still willing to fight for people.
• 35:21
  Yeah.
• 35:21
  Yeah.
• 35:22
  Um, but you know, some of these things, they're not allowing us now to have peer to peers.
• 35:22
  Um, but you know, some of these things, they're not allowing us now to have peer to peers.
• 35:29
  That seems
• 35:29
  That's infuriating because there's no one, like some of these specialty pharmacies, they don't have doctors on staff anymore.
• 35:35
  It's just this clinical AI that's throwing these decisions out.
• 35:40
  And like literally, we've we've asked for a peer to peer.
• 35:43
  We can't do that.
• 35:44
  We don't have anyone eligible.
• 35:46
  There's there's not a peer.
• 35:47
  So to be a peer, you have to be like the other person.
• 35:51
  You have to be a physician, a peer to peer, and there's not one there.
• 35:57
  That how I don't understand how you get away with that.
• 36:01
  Like, how is that even legally correct?
• 36:03
  I it's infuriating.
• 36:07
  Yeah, and I the number one thing that comes to mind is it's all about cost.
• 36:13
  What's driving their decisions is not on medical necessity, which it even said that in the letter that you received.
• 36:20
  Our decision was not based on medical necessity.
• 36:24
  So I mean, that just tells me their number one priority is cost savings.
• 36:29
  And what I was also talking about in the first segment is we are quick to blame the insurance company, and ultimately they do have a lot of responsibility in this, but one person that kind of skirts around is the employer.
• 36:45
  Right.
• 36:46
  Because they're the ones that design this and go with certain companies with their priority being cost savings.
• 36:53
  Right.
• 36:53
  Our current insurance company hasn't really given us a huge pushback.
• 36:57
  They have given us pushback, but they've always made peer to peers an option and they've always um been open to appeals.
• 37:04
  The letter we recently recently received came from a specialty pharmacy that um our company has mandated.
• 37:15
  It's it's a mandated specialty pharmacy, so it makes it very difficult to find the loophole.
• 37:22
  Um we are prepared to go back to the employer and say, look, you hired this company, this medication that our son is living from that he's been on for over two years, it's not a formulary.
• 37:36
  So, hey, you need to come back and help us and let our our actual insurance company cover it.
• 37:42
  So, and you could talk about that for a little bit if you want to, because there's you know, it's as a process, but if you can't get your specialty pharmacy to cover something, and it's my understanding if it's not in their formulary, it makes it difficult, and then you can go back to your employer and be like, um, you have to fix this.
• 38:03
  Yeah.
• 38:04
  Yeah, I mean, there's they can make exceptions on so many different things.
• 38:10
  Um, and a lot of people stop at the insurance company, but sometimes you have to go beyond that and actually go back to your employer.
• 38:19
  Um, you know, for instance, I worked with someone who had a child with um autism and needed, and and I'm talking young, like you know, five, six years old, needed speech therapy, occupational therapy, physical therapy, and with their insurance company, they were limited to 35 visits a year.
• 38:42
  Wow.
• 38:42
  Well, when you have a child going three times a week with all the different therapies, you're you're blowing through those visits, and then you're left with nothing except to pay out of pocket, which is insane.
• 38:56
  Right.
• 38:57
  So the insurance company, their hands were kind of tied because that's what was in the plan.
• 39:04
  And so you have to go to the employer and say, we need you to make an exception for this child.
• 39:11
  And they did.
• 39:13
  They they did make the exception.
• 39:15
  But when you think of that on a large scale, an employer that employs thousands of people across the United States, this one child is not the only child that was needing that much therapy, right?
• 39:26
  Like there's other people.
• 39:28
  So, and eventually, with people pushing back, the employer did change their plan.
• 39:35
  Um the employer that provides you and your family with insurance is interesting.
• 39:42
  I didn't even know this was a thing, but they create the insurance plan.
• 39:49
  The insurance carrier does not.
• 39:51
  So it's a contract.
• 39:54
  It's a contract.
• 39:55
  So they design it, they create it, they decide what they want in it and excluded what they'll cover, not cover, um, the deductible, the maximum out of pocket, everything the employer decided.
• 40:08
  But who do people get mad at when they're unhappy with their insurance plan?
• 40:13
  Right?
• 40:13
  The insurance company, yeah.
• 40:15
  Yeah, yeah, yeah.
• 40:16
  Yeah, they don't know to go to HR, they don't know to go to the company's ethics department.
• 40:21
  Yeah.
• 40:22
  Um, and this information is withheld just to keep people from fighting.
• 40:28
  I believe that with all of my heart because they don't promote it, right?
• 40:32
  Like when you get hired on, they're like, they're not like, guess what?
• 40:35
  We created this for you because they know they don't want the pushback.
• 40:42
  Right.
• 40:42
  It makes me so angry.
• 40:44
  I was blown away when I found that I had no idea.
• 40:47
  I just I like I was saying earlier, um, you know, when I was choosing my health insurance with a hospital that I worked at, I was just like, I can't believe the insurance companies get away with this, you know, with the high deductibles and the high out-of-pocket maximums and stuff.
• 41:04
  And lo and behold, it was probably the hospital that I worked for that created the plans that we were choosing.
• 41:11
  Never would I have thought that they had anything to do with it.
• 41:15
  It was just who they chose to go with.
• 41:17
  Um, so there's a lot unknown, and I think that that's where people get overwhelmed and just kind of give up.
• 41:27
  But well, and and you've got these annual open enrollments, every company has them open enrollments.
• 41:33
  So you don't know what's going to change on January 1st.
• 41:37
  Right.
• 41:38
  You just don't know.
• 41:39
  And they'll be like, here's a few changes, and that's that's what happened to us.
• 41:44
  We were just expecting a continued care.
• 41:49
  And then it was like January.
• 41:53
  No, it it was it was February.
• 41:56
  So February, they told us that we had to now go through the specialty pharmacy.
• 42:00
  Now go through the specialty pharmacy.
• 42:02
  And then it wasn't just specialty, it was a mandated specialty pharmacy.
• 42:02
  And then it wasn't just specialty, it was a mandated specialty pharmacy.
• 42:06
  It's like, how can you mandate a company that doesn't even carry the medications that our kids need?
• 42:06
  It's like, how can you mandate a company that doesn't even carry the medications that our kids need?
• 42:13
  I don't I don't know how it infuriates me.
• 42:13
  I don't know how it infuriates me.
• 42:17
  How do they get away with it?
• 42:17
  How do they get away with it?
• 42:18
  Do they just not know themselves?
• 42:18
  Do they just not know themselves?
• 42:20
  Like, are these people coming out of college?
• 42:20
  Like, are these people coming out of college or these specialty schools?
• 42:23
  Are these specialty schools?
• 42:25
  And they're they're just like seriously.
• 42:25
  And they're they're just like seriously.
• 42:28
  How can you not know some of
• 42:28
  How can you not know some of this stuff?
• 42:30
  We called um the employer and filled them in on the situation.
• 42:37
  And they transferred me to the benefits department manager, and that manager had no idea.
• 42:43
  She was like, okay, can you tell me this again?
• 42:45
  I'm writing this in detail.
• 42:48
  And like she said, what are we doing?
• 42:51
  And I was like, You you don't know what you're doing.
• 42:54
  The company.
• 42:55
  The company didn't even know.
• 42:56
  And so in their words, they thought the specialty pharmacy, you know, it was going to save the company money, but they really thought it was going to be a benefit to the employees.
• 43:06
  No.
• 43:08
  Somebody higher up knew better than that.
• 43:11
  But that's how they sell it to the employees.
• 43:13
  Because, you know, if if if you think about it with insurance companies, with employer, like it's not all the all the people aren't bad.
• 43:21
  There's people in these positions that truly think that they're they're doing the right thing.
• 43:29
  Yeah.
• 43:29
  And then, you know, and then the longer you're in it, the more you realize.
• 43:34
  I mean, I work for an insurance company, and I thought, well, I'm the one fighting the system within the system, you know, and I and I do, but that's the longer that I am there, the more evil you see.
• 43:52
  And you can't unsee what you've seen.
• 43:55
  And I don't think I don't think there's anybody sitting there saying, I want these people to suffer, you know.
• 44:02
  But I do think that they think about profit over the patients.
• 44:09
  They do.
• 44:10
  So do they really know what it is?
• 44:12
  They have to.
• 44:13
  They don't know.
• 44:14
  It's a business.
• 44:15
  If you think about it, hospitals are a business.
• 44:18
  Yes.
• 44:19
  They have to be.
• 44:20
  That's why I don't work there either.
• 44:22
  They they have to make money to stay in business.
• 44:24
  Yes.
• 44:25
  Um but at the same time, I I really do think that something needs to be done that we don't continuously have, like, not we, but hospitals and insurance companies and employers have the right to overcharge their people.
• 44:41
  Yeah.
• 44:42
  For what for a denial letter.
• 44:46
  Yeah.
• 44:46
  Well, and they, you know, they deny, which delays the care.
• 44:51
  And if you like, just to make the numbers easy, like let's say you have there's 10 denials, you're not gonna get 10 appeals.
• 45:02
  So maybe only like six of those appeal.
• 45:06
  And then out of those six appeals, maybe only three or four get overturned.
• 45:11
  So they saved money, you know, insurance companies profit by bringing in more money than they pay out.
• 45:18
  So a tactic that um that they will frame as, and I believed this, and I still do think that there's truth to this, but they have these processes in place to prevent fraud and abuse.
• 45:35
  So a doctor who just orders stuff all the time that's just really unnecessary just to be able to bill for it.
• 45:43
  And that does happen.
• 45:44
  I mean, I've seen it, it happens.
• 45:47
  Um, but I don't think that that is the the only reason.
• 45:51
  I think that maybe it started out that way, and then they realized, oh, we can save a whole lot of money doing this and framing it, and that we're trying to help you.
• 46:01
  You know, we're we're protecting you.
• 46:04
  Um, but then you see people's cardiac casts are being denied, their hospital stays are being denied, their back surgeries are being denied.
• 46:13
  God bless them.
• 46:14
  I had a mom who's whose child was disabled, his wheelchair was denied.
• 46:23
  Like, what are we doing?
• 46:24
  You know, um, it's just it's become a very corrupt system.
• 46:29
  Right.
• 46:29
  Which one yeah, and I don't want to be like saying they're always denying life saving measures, but sometimes life altering denials feels very, very much it feels very heavy.
• 46:47
  And because when your life is so altered that you don't even know what normal is even more, yeah.
• 46:54
  Is that even living?
• 46:56
  It's just you're in survival mode as a family, and I think insurance companies need to get back to seeing the whole picture, not just the patient, but the whole family, the whole picture, and um, and I think that's why so many places are you know, people are turning to holistic places, holistic modalities.
• 47:14
  Um, we've recently had an influx of people come to remnant.
• 47:19
  Yes, yeah, because they're they're tired of sick care, they're tired of the denials.
• 47:25
  And no, we we don't take insurance at remnant, so you're not gonna have to cross that hurdle.
• 47:31
  But you know, there's a reason we don't because we we don't want our, we don't want to dip our pinky toe back into the sick care.
• 47:40
  We want wellness, and I I think we have a whole person, a whole family philosophy, and like we really care.
• 47:47
  And I and you see more and more people branching out to do this, and I really do believe that if people can branch out and do that, why can't insurance companies just bend a little bit and remember hey, they're human, we're dealing with humans.
• 48:01
  And I could go on and on.
• 48:03
  It just no, it's it's true.
• 48:06
  And I I do feel a shift, and I don't know what's gonna happen because I feel like the um healthcare system and the insurance system, they're so big that I don't know how you reel that back in, you know, and and change it, but people are gonna leave and they are searching for alternatives, and and then you you know, you get the pushback of well, you know, paying out of pocket is so expensive.
• 48:34
  But and for your case, IVIGs, like 38,000 or more, yeah.
• 48:41
  Um that's just the med, you know, then you have to think we need the insurance.
• 48:45
  You honestly need the insurance, they can't just go pay that.
• 48:48
  And should it be that expensive?
• 48:50
  I mean, that's probably a whole nother show.
• 48:52
  But um, but for for the average person, if you really think about how much you pay in premiums every month at the end of the year, if you saw like a functional medicine provider and you spent not even a quarter of that on paying out of pocket, you're actually saving money.
• 49:00
  At the end of the year, if you saw like a functional medicine provider and you spent not even a quarter of that on paying out of pocket, you're actually saving money.
• 49:14
  And to work with somebody who can truly provide health and healing and preventative medicine, um, you know, it in the long run, you really are saving a lot of money.
• 49:14
  And to work with somebody who can truly provide health and healing and preventative medicine, um, you know, it in the long run, you really are saving a lot of money.
• 49:26
  And um, but that that's hard.
• 49:26
  And um, but that that's hard.
• 49:28
  People are very fearful of.
• 49:28
  People are very fearful of going without insurance.
• 49:32
  Right.
• 49:32
  But I think something has to change.
• 49:34
  Um, a lot of doctors are changing their practice.
• 49:37
  My pediatrician no longer takes insurance, they only do concierge services.
• 49:43
  You pay a membership fee and and can see your provider.
• 49:46
  And I've seen that happen a lot.
• 49:49
  Right.
• 49:50
  I mean, we we just um were blessed with meeting with a doctor here in Atlanta that is offering functional medicine and you know, does not go within the insurance company.
• 50:03
  Um, and so yeah, it's it can be expensive, but ultimately if you're you're getting better and you're getting answers and you're getting someone that actually cares about you, you know, it's worth it.
• 50:17
  The problem is um you can't always opt out of insurance.
• 50:21
  And I believe your your husband's employer is that way.
• 50:26
  Um, the day that you're hired, you're enrolled, and you have to prove that you either have like Medicaid or Medicare or some other form of insurance, otherwise you are forced to have that insurance, right?
• 50:39
  Right.
• 50:40
  Right.
• 50:40
  Yeah, it's I don't know.
• 50:42
  It's an overreach for sure.
• 50:46
  Yeah.
• 50:46
  Yeah, because I I mean ultimately it it's up to the individual.
• 50:52
  My my philosophy used to be a lot different.
• 50:55
  I used to think, well, yeah, people should have insurance because then you come to the hospital, you're the ones that are running up hospital bills and then aren't paying them.
• 51:05
  So then hospitals are trying to recoup this money, and that's why they have to charge so much.
• 51:10
  And I've since been very humbled in that opinion because I, you know, I I think that a lot of that came from nursing school and then um, you know, being in the environment that I was in working in the hospital.
• 51:25
  That that is the narrative that you're you're fed, and it's it's kind of far from the truth.
• 51:32
  Yeah, it is.
• 51:34
  I don't think you see the truth until you're you've been you've been in the system.
• 51:38
  Like you've you've been in it, whether it be as a nurse, a doctor, or the parent, the caretaker.
• 51:43
  I don't think you fully understand the impact of of the weight that these families are carrying until like you've been there.
• 51:50
  Um you can't truly have a heart of empathy unless you have empathetically suffered the same thing.
• 51:57
  Yeah.
• 51:59
  Yeah, I I definitely my eyes were were open to a lot of things after, you know, working in the hospital and and seeing this day by day.
• 52:09
  And you know, I do have a little bit of a confession and we're running out of time.
• 52:13
  So hopefully nobody gets mad at me for saying this.
• 52:16
  But back when whenever it was, I forget what year, when Obama was running for his second term, he basically ran on fixing the health care system and getting health insurance that everybody could access and afford.
• 52:32
  And I was like, yeah, let's go.
• 52:34
  Because nobody else was talking about it.
• 52:37
  People were really excited that somebody was actually going to do something.
• 52:41
  And I was all for it.
• 52:42
  Well, around that time, um, when it got implemented, the Obamacare, that's when I graduated nursing school and started working in the hospital.
• 52:54
  And so I thought for sure, all of these people that I had seen, you know, in my rotations through nursing school that were underserved and didn't have access to insurance.
• 53:04
  All these people were gonna have insurance now.
• 53:06
  Like it was gonna be great.
• 53:07
  Everybody was gonna be covered.
• 53:09
  And that was very far from the truth.
• 53:12
  There were actually probably more people that didn't have insurance.
• 53:17
  Um, private practices were shutting down.
• 53:20
  People could not afford insurance, and then they were faced with having to pay a fine if they didn't sign up for insurance that they couldn't afford in the first place.
• 53:32
  It was a mess.
• 53:33
  And it really, I think destroyed the insurance system.
• 53:37
  I agree.
• 53:38
  I wholeheartedly agree because it wasn't always this bad.
• 53:42
  No.
• 53:43
  No, I wish it was something that I, you know, looking back, I'm like, oh, I was so naive.
• 53:48
  But I think I was excited for change because the system was broken and nobody was talking about how to fix it.
• 53:58
  So I don't even know the the Maha movement.
• 54:01
  I had so much hope for, but I don't know if everything we want to get fixed is going to get fixed.
• 54:10
  I just and that's another problem in itself because you know, each administration they have four years to do things.
• 54:17
  And then the other one comes in behind them and just unclear.
• 54:22
  Yes.
• 54:23
  Yeah.
• 54:23
  I mean, I think when Biden came into office, he just reverse every single executive order.
• 54:30
  So you kind of they can't just do executive orders, they have to make it permanent.
• 54:35
  And then that that takes time, you know, and so I don't know how far we're gonna get.
• 54:39
  I'm gonna stay hopeful because I have to stay positive, but um, I I think it's it's going to take a long time to fix, but I really don't think people are gonna wait around for it and they're gonna seek alternatives.
• 54:54
  So even like with remnant, you pay a monthly membership, and you can you can have telehealth services.
• 55:01
  We have a nurse practitioner, we have nurses, we have health coaches, we can order labs and whatever it is that you need.
• 55:06
  So exciting.
• 55:07
  It's so much easier, shape.
• 55:08
  I mean, you're not waiting, you're not waiting for a decision.
• 55:11
  We just get busy.
• 55:13
  We get busy.
• 55:14
  You call it.
• 55:15
  Yeah, I mean, I've gotten a test.
• 55:17
  Hey, we got a new client.
• 55:18
  When can you see them?
• 55:19
  And I'm like, well, I have some openings this afternoon.
• 55:21
  Like, you know, just let me know.
• 55:23
  And um, you know, so it's not like you're waiting.
• 55:26
  I I have uh a patient that had a stroke first time.
• 55:31
  She's never had a stroke before and very terrifying.
• 55:36
  Um got discharged from the hospital to follow up with her neurologist, they'll see her in five months for her initial visit.
• 55:46
  Wow or post-hospital follow-up.
• 55:48
  So it's insane.
• 55:49
  I mean, um, there's definitely a delay in care across the board, whether it's insurance, lack of providers.
• 55:56
  Um I I even had a primary care provider the other day tell me, well, we don't just take people.
• 56:00
  Or the other day tell me, well, we don't just take people.
• 56:04
  We have to make sure that we want to see them.
• 56:04
  We have to make sure that that we want to see them.
• 56:08
  And so you have to submit all this information and then they review it.
• 56:08
  And so you have to submit all this information and then they review it.
• 56:12
  And then a week or so later, they'll let you know if they'll even take you on as a patient.
• 56:12
  And then a week or so later, they'll let you know if they'll even take you on as a patient.
• 56:17
  So it it's gotten really bizarre out there in the world.
• 56:17
  So it's gotten really bizarre out there in the world.
• 56:21
  So you guys hang on, stay strong.
• 56:21
  So you guys hang on, stay strong.
• 56:23
  Um, but we we are out of time.
• 56:23
  Um, but we we are out of time.
• 56:26
  Any last thoughts, any um advice that you would tell somebody?
• 56:26
  Any last thoughts, any um advice that you would tell somebody that's maybe facing a denial?
• 56:32
  Don't give up.
• 56:34
  Yeah.
• 56:35
  Fighting.
• 56:36
  Fight the good fight and get some help to fight.
• 56:40
  Yeah.
• 56:41
  Call us.
• 56:41
  Call me.
• 56:42
  Call Remn.
• 56:43
  Yeah.
• 56:44
  We I mean, and if we don't know, we we have a whole team of people that um support us and can help.
• 56:52
  But there's there's a lot of experience um at the Remnet team.
• 56:56
  So don't do this alone.
• 56:58
  You guys don't have to fight this alone.
• 57:00
  That's true.
• 57:01
  Thank you everybody for hanging in there with us today.
• 57:05
  I appreciate it.
• 57:06
  If um, you know, there will be a live show on America Out Loud, weekdays at 10 a.m.
• 57:14
  and then the onpour at 11 p.m.
• 57:17
  We'd love to hear from you.
• 57:19
  So feel free to reach out to us if you have a suggestion for a show.
• 57:23
  But thank you guys for joining us today.
• 57:26
  God bless you.